23
Tapping Voluntary Resources
in the Welfare
State THE PRACTICAL PROBLEMS MURIEL SKEET
Consultant, W.H.O. Headquarters, Geneva, formerly Chief Nursing Officer, British Red Cross Society HERE ARE many definitions of the word ’role’, a generally accepted one is that it constitutes the behaviour expected of an individual by virtue of his occupying a specified position in a social situation (Gilmore et al. 1974).’ Role expectations are perceptual, existing in the mind of the performer and in the minds of those with whom he associates in carrying out his work. But,expectations do not remain in the mind. They tend to become communicated, sometimes as direct instructions, at other times less directly; for instance, when admiration or disappointment in some performance or behaviour is expressed by a colleague. Low congruence in perceptions among group members in regard to their roles may not only be disfunctional for the provision of a service, but may mean that the individual feels his identity is not being recognised and respected by those with whom he works. Defining ’volunteer’ is more difficult for there is more than one category of such a person. The Working Party on the ’Place of Voluntary Service in Aftercare’ appointed by the Home Office under the Chairmanship of the Dowager Marchioness of Reading in its second that is to report2 distinguished between associates say volunteers ’who can provide support for a considerable period by a personal relationship’, and other volunteers ’whose contribution is more likely to be of a short duration in the way of a simple practical task or advice on a technical problem not requiring personal involvement’. The Working Party drew attention to the fact that ’there will always be truly independent persons and organizations who do not want any official contact or recognition and yet wish to offer a service’. Ten years later, another study designed to discover the role of the volunteer in the re-organised Health Service confirmed that statement.33
but
-
TEAM MEMBERSHIP ONE OF THE recommendations from that study was ’Volunteers in the health field working in the community should form part of the Primary Health Care Team and a member of that team should be responsible for their in-service training, their supervision, their follow-up assessments and for giving them continuous encouragement and support. Similarly those working in hospitals should come under the supervision of a senior member of the nursing staff to whom they should be responsible and accountable’. Integration as a member of the team is difficult if not impossible if the volunteer is responsible to a lay organiser whilst all other members are responsible to a senior member of one of the professions. A task should only be delegated to a volunteer and accepted by him if he is safe in carrying
out the procedure. An must be the judge.
expert in that particular field
It follows that accountability is something which given very careful consideration as the personal responsibility of each individual professional member of the team must be borne in mind. For this reason, every member of the team - whether professional or amateur - must be fully informed of the others roles, duties, specialised skills, interests, and responsibilities and limits of competence. The characteristics which occur with the greatest frequency in the literature on team work and which are considered to be most important in its development, have been set out by the authors of ’The Work of the Nursing Team in General Practice’.4 must be
These are: (i) that members of the team share a common purpose which binds them together and guides their actions (ii) that each member of the team has a clear understanding of his own functions; appreciates and understands the contributions of the other (professions) represented on the team and recognizes the commonness of interest and skill (iii) that the team does the practising by pooling knowledge, skills and resources and that all members share responsibility for the total outcome of their decisions. (iv) that the effectiveness of the team is related both to its capabilities to carry out its work and its abilities to manage itself as an independent group of people. Leadership only becomes a problem when there is lack of mutual respect and trust. The report of the Panel on Primary Health Care Teams (British Medical Association, 1974)5 stated: ’As the team is composed of members from a number of complementary disciplines, it is essential to define the objective of all its members so that there is a clear definition of their roles’. To learn a professional role, one goes through a specific educational programme designed to teach those skills and give that knowledge essential to carrying out the work within that role. Training is also a means of introducing a newcomer to the expectations of other members of the team and of providing them with the opportunity to identify with it. Surely this must apply to the amateur in the health or social service team, as well as to its professional members. However, in order to integrate the volunteer (who, we must remember, is not always an amateur) it is
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24 necessary to have the acceptance and the co-operation of three parties: the volunteers themselves, the professionals and the patients. In considering the practical problems met with in tapping the voluntary resources which is my remit I suggest we take each available of those groups in turn. And whilst there are many publications and reports including the latest one on Voluntary Organizations produced by the Wolfenden Committee6- I intend to advance ideas and base opinions on personal experience and gleanings I have had the privilege to gather during my own professional life. First in order of priority and importance - the -
-
-
-
patient. PROBLEMS OF THE PATIENT FIRST THE needs, and then the problems encountered in trying to get them met. I make no apology for including in the needs, those which were discovered during an enquiry undertaken eight years ago.’ I offer only the explanation that I know - and most of the audience will know - that similar experiences are to be found today. With more people living longer, the plight of old people, especially those recently discharged from the security, warmth and servicing of hospitals and Homes, occupies the attention and the conscience of many a social worker. The burden also falls squarely on the shoulders of the nursing members of the Primary Health Care team. We have known the curing role of the medical profession: that medical intervention is frequently dramatic and puts doctors in the teamleader position. But we are moving to new and expanding roles for other professions, because the people we keep alive longer rightly or wrongly - give nursing intervention an important place. This applies not only to the phenomenon of longevity, we also have disabled and drug- and machine-dependent patients living in the community who, a few decades ago, would have been dead. Those of you who have read Home from Hospita 18 will remember that examples were given of the different needs of patients discharged from hospitals. A variety of thumb-nail sketches were presented. These have sometimes been criticized: called journalese or described as the ’worst’ examples the study team discovered. They were neither. They were factual case histories written with no comment. Those unmet needs described in the report, included basic nursing procedures, such as the renewal of a dressing, the installation of ear or eye drops, help with dressing or undressing, bathing, washing, getting to the W.C. etc. Then there were a large number of patients who needed inforand their families and friends mation, advice and reassurance; elderly patients who had fractured their femurs missed the reassurance and encouragement of physiotherapists; others needed advice on rest or activity, or the expected effects of treatment such as chemo- or radio-therapy; on diets; on appliances and prostheses; on drugs and pain. Young mothers needed help with new babies. Old people requiring chiropody were housebound for no other reason but that their toe-nail problems prevented them from walking. Of course people do receive advice and instructions before discharge, but the older ones forget quickly and the younger ones confessed that they had not really -
-
-
paid attention; they were too excited, or preoccupied with the practical problems about going home. Others did not know about the services which were available locally; these included the laundry service, the
lending of for which
nursing equipment and the financial benefits they were eligible. Help with shopping, cooking, washing-up, bedmaking and also housework and gardening was often required, whilst the homehelp service requested sometimes did not materialise. Patients in the higher age group, especially surgical and orthopaedic patients, those with long-term illnesses and those living alone, experienced the greatest inconvenience. Relations, friends and neighbours often rallied but patients disliked the resulting feeling of obligation and dependance. Relying on relations not living with them produced anxiety because of the uncertainty involved and some people spoke of having to wait until the evening to be helped to the bathroom or to have their bed made, because this was the only time their helpers could come. Although no questions were asked about the serving of food, several women patients spoke of this and of the husband-produced or child-produced meal trays, carrying a whole plastic bag of bread and milk still in the bottle. ’Just one meal a day served with the feminine one said, ’would make so much difference. And of you may remember the example I gave of the patient who needed a listening post: Mrs. Z. Aet. 30 years. Acute lymphatic leukaemia. Chemotherapy and radiotherapy. Anxious for discharge to husband and two-year-old son. After discharge she missed the security hospital had given. Afraid of ’collapsing’ and of symptoms becoming too distressing. Attempted to take up the domestic responsibilities and the gay social life she was used to but felt weak and tired. This inability to do what she wanted, and her physical appearance, including swollen neck glands and poor condition of skin and hair, aroused frustration and anger which quickly led to depression, tears and temper. She hated the radiotherapy outpatient department and waiting with other patients ’gloomily discussing their symptoms’. Yet Mrs Z. was aware that this was her own great need. She did not want to bore her friends and distress her family and ’desperately wanted someone to talk to whom she did not know.’ She was ’smothered’ by family and friends who wanted to help, yet she could not use them - they were too close. Her great need was for ’a stranger who would listen’. Those then were some of the needs which were discovered. Nothing new, but to put facts down in black and white produces ’ammunition’ for people to fire. Identical needs were still unmet six years later, when another study to discover the role and preparation of volunteers was undertaken.9 In addition to those described above, it was established that there were increased needs in the fields of rehabilitation and health education. Stroke patients and their families needed instruction and encouragement with speech and physio-therapy; relatives needed to be taught how to perform competently basic nursing procedures and techniques which they were having to undertake at home for ill and infirm members. Again mothers needed on-going education: with non-accidental injury to young children,’° the increased incidence of head-lice, impetigo and rickets one cannot ignore this large field which presents scope for the well-informed volunteer. Young housewives knew little or nothing of first-aid; accidents cause more deaths among children in this country than any one disease. Who are the Lay volunteers? experts in that subject? Among the services recommended&dquo; to receive urgent attention were:
touch’, some
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...
25
(a) (b)
in half-way houses to provide accommodation and necessary services for old people. A door-to-door transport service for ill and elderly patients discharged from hospital or care
undergoing regular treatment as outpatients. (c) Home-help and Meals-on-Wheels service operating daily; the lay staff receiving support and encouragement from professional members of the Primary Health Care team. (d) A night-sitter service to relieve families and friends of patients who are ill or dying at home. (e) Organization of voluntary helpers of all ages to cook, serve meals, garden, shop, launder, do housework and to provide company, interest, and encouragement for those in special need, particularly the old and the lonely. Most of these services do not require to be delivered by someone with a training of three years or more; many needs could be met by a well-prepared and, in some cases, an adequately trained volunteer. Why were they not? From the patients’ points of view, primarily because they and their families did not know about already existing services and they did not know how to set about creating a demand for those not available. And when they had a vague idea that something of the kind existed, they did not know where to go for it. Another problem especially highlighted in rural areas, was the patient’s resentment of any intrusion of his privacy by a neighbour. It is for this reason that some street-warden schemes which have been initiated in various areas of this country, have failed; the patient or his family do not want neighbours seeing inside the home, finding out that the linoleum is torn or that the sheets are darned. Pride can be a mixed blessing...
because of lack of personnel. The earlier discharge of from hospital had brought more demands in some areas than their members could possibly cope with. Preparation of homes for patients returning from hospital was considered an important service, and one for which more helpers were needed. One Centre had found that a good source of supply for this particular service was retired nurses who, suffering ’from the ’scrap-heap syndrome’ in the late fifties and sixties, were delighted to find that they could be useful again. Often the ’established’ organizations said that it was difficult to recruit because ’everyone goes out to work these days’. Yet the vast majority of volunteers from ’new’ associations and also the independent volunteers interviewed, were in full employment. In fact many of the services were needed during, what are, for most the early morning, late people, non-working hours evening and at weekends. Experience has proved that telling people about a particular need in their own community usually stimulates offers of help. People rarely offer help in a vacuum, they need to be aware that their help is needed. Just as they want to know how their money is going to be used before giving it to a Charity, so they will also want to know how their time will be spent before offering it to a voluntary organization. Many will also need assurance that preparation for the job will be
patients
-
forthcoming. By involving the community in discovering the needs on its own doorstep, members of it will often proffer ideas on how to meet them. They will also help to implement plans, and, finally, help in their evaluation. On-going assessments of their work and services are sadly absent from the plans of most voluntary organisations. Some have become introspective and continue without question or judgement, their traditional forms of service
PROBLEMS OF THE VOLUNTEER AND VOLUNTARY ORGANISATIONS SADLY THESE two studies also made another discovery ; the services needed were not always those which volunteers wished to provide. Some services are more popular than others and this explains, to some extent, the duplication of services which exists. Unfortunately some organisations provide a service they consider necessary rather than finding out by local surveys, what is actually needed in their area. In the first study, Home from Hospital, no detailed description of the work of any individual member of staff of either a statutory or a voluntary service was obtained; only a superficial picture of the organisation and of the delivery of its services was asked for. Organizers for the W.R.V.S. reported understaffing in both areas where the enquiry took place. Young women, they said, were employed by local industry and many who would have helped the W.R.V.S. had nowhere and no-one with whom to leave their children. The time spent in talking to people was considered important but often had to be cut because of the pressure of numbers. Helpers often reported adverse home conditions and particular cases of hardship they encountered. Whilst social workers were usually sympathetic, they could not always respond because they too were working under considerable pressure. Volunteers ’signposting’ in this way without contributing to solutions, added to the professionals’ load instead of helping to ease it. Recruitment was also a major problem of the Red Cross officers included in the study. They reported that requests for help frequently had to be turned down
others dabble in so many activities that they provide no one excellent service. Instead of searching for solutions to today’s problems, many opt for palliative measures. Often they are seen as ’not doing very much’ - a state not likely to attract new recruits. If voluntary agencies are to make their mark and obtain publicity they must earn it by providing services which are needed. Sometimes the service offered may be the right one, but is given under the wrong circumstances. As one patient with a progressive disease said, ’The voluntary organizations will provide transport to attend their own clubs and outings, but I don’t necessarily want to be with people with whom a physical disability is the only thing I have in common. I should like to visit my own friends for a meal, but transport to enable me to do so is just not there’. The time a service is available is also important. One of the greatest gaps in the statutory services is caused by the closure of departments at weekends and over Bank Holidays. Yet many voluntary organizations close at the same times. Medical Loan equipment is often needed at weekends but in many areas the depots of both statutory and voluntary agencies close down from Friday afternoon to Monday morning. In many parts of the country, the statutory meals-on-wheels service is discontinued for four or five days over Easter and Christmas: so is that of voluntary organizations. Too often, volunteers and voluntary agencies are providing the services they want to provide and not those which the patients/clients need. It has been made clear during group and individual discussions in which I have been involved, that greater co-ordination, collaboration, communication and co-
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26
operation are vitally needed not only between statutory and voluntary sectors of our Welfare State, but also between the voluntary organizations and volunteers themselves. Individual characteristics should be preserved, but to save the professionals’ time and also to be able to meet the need quickly, the voluntary organizations should consider Seebohm’s one-door principle. Not only would it provide one telephone point where all requests for voluntary help could be made, but it would also provide one recruiting point and a centre for the deployment of volunteers. Jack Ashley’s comments on associations for the deaf have wider implications: ’There are too many fragmented organizations, each dealing with its own specialized aspect of the problem and in many cases with specialized groups of people. At present, despite some attempts to co-ordinate their activities, deaf organizations leave themselves vulnerable to petty jealousies and parochial conflicts’. These petty jealousies and parochial conflicts result not only in a waste of resources, but also contribute to people’s general confusion and ignorance regarding voluntary
organizations. During our fieldwork, the following statement from the Report of the Committee on Local Authority and Allied Personal Social Services (Seebohm Report 1968) 12 was underlined time and time again: ’The ways in which existing resources are organised and deployed are inefficient. Much more ought to be done in the fields of prevention, community involvement, the guidance of voluntary workers and in making fuller use of voluntary organisations’. At the present time there appear to be minimal results from the many services voluntary workers offer. The low awareness of agencies and volunteers is indicative of this. Whilst there is an enormous investment of devotion there is a deplorable lack of return. The whole subject of preparation and training of Volunteers working in the Welfare State requires more study. However it is believed that all training should include the three elements of knowledge, skill and understanding. Obviously preparation or training for a job depends on the job to be done. But any amateur working with a patient or client requires at the very least, briefing on matters such as confidentiality. The Aves Committee (1969)&dquo; thought that ’volunteers who will be involved in close personal relationships, whether their work is the befriending of a lonely person or is concerned with helping people who have complex problems, will need, above all, to know something of human reactions and behaviour. They may need help in understanding the feeling and attitudes of clients and in realising that the relationship has to be one of mutual acceptance. They need to learn something of the arts of communication and establishing relationships, of how to give and receive information and respect confidences’. It is important too, that they should be able to judge how far they can go in dealing with a difficult situation and when and where to turn to for advice and help. In planning training it is necessary to bear in mind, not only the demands which the work will make on the volunteer, but also his own experience, capacity and attitudes and the resources which are available for training and continuing guidance or support. The amount of information, skill or awareness which volunteers may need to acquire will depend on these factors and will vary greatly, but it is essential that each volunteer should be helped to see how his learning can be applied to his work. Any training scheme which fails
to enable him to
apply his knowledge can achieve little, defeat its aim by confusing him or undermining his confidence. Who is to provide that preparation? That training? After the Second World War, trained V.A.D.s were accepted members of the ward nursing staff in many hospitals in this country. Members of the National Hospital Service Reserve received their training and gained their practical experience in hospitals of the N.H.S. Ward Sisters knew what tasks they could be called upon to undertake because, more often than not, they had taught them. It would seem logical that today’s professionals should train or prepare today’s volunteers to be their assistants. and may
even
PROBLEMS OF THE PROFESSIONALS DO THE professionals want that task? Do they want volunteers who will help them in their work? What about their reputation of being unreliable? What about Trade Union repercussions? Legal implications? The possibility of litigation? Certainly it would appear that there is an urgent need for professional staff working for the Welfare State to be prepared for working with volunteers. They must see them as assistants to themselves, working under their supervision: volunteers are not, and must never be seen as, alternatives to professionals. Even in times of emergency and epidemics, they must always be supervised by qualified staff. But in order that they may be effective and competent at those times, they must be given opportunities to practise in real-life situations. Professional members of the health and welfare teams should also be provided with information concerning voluntary organizations, their work and the services they provide. Such preparation should be included in their training programmes. It is not the exclusive right of the so-called caring professions to help people. Today we have a caring community. ’Health by the People’’4 is not only for Third World countries. Now, as never before, there is the need and the opportunity for professional staff members of the Welfare State to work with, as well as for, the community. People helping people has been the backbone of British social life for centuries, and although it may be called consumer participation in our time, nevertheless, help in this form is still needed. Self reliance must be taught especially in the preventive and promotive fields of medicine. Here people can help people to help themselves taught initially by -
-
qualified personnel. Voluntary organizations with their unique pioneering function can implement innovative programmes without waiting for Committees to be convened or for questions to go up the scale and answers to slowly return down again. It is for this reason that Voluntary organizations must stamp on any sign of bureaucracy if
it appears in their midst and it is for this reason that they must never allow themselves to be totally Statefinanced. Their independence is their strength. They can - if their leaders are imaginative and courageous provide a service when it is needed, where it is needed and for whom it is needed. Can we afford not to use volunteers in the Welfare State? Studies have shown that in Britain we are -
deploying community nursing personnel inefficiently. 15 have expensively trained staff with high qualifications and great experience, who are sometimes used ineffectively. How can we conserve our resources? We
The cost of the National Health Service for 55 million
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27 in the United Kingdom is 75 times the annual of the World Health Organisation. 16 This cost has increased explosively during the past 15 years. Administrative changes were brought about in 1974 to help organise services in a more economical way. Has this been achieved? It may be that health care can be better and more economically achieved by different combinations of disciplines, professionals and auxiliaries. We have an obligation to save skilled time which is a most expensive commodity. Yet health professionals in particular have this inbuilt resistance to health auxiliaries. In a recent global study of the subject it was shown time and time again that resentment at the deployment of auxiliaries came from doctors and nurses and the greater of these came from nurses.&dquo; Health service is an open-ended commitment and more can always be done given the resources, material and human. Have our professions the right and the conscience to limit those human resources? The health professions are notoriously conservative and understandably so they undertake onerous responsibilities and part of their personal defences against doubt arise from the established certainties within their professions and sciences. But we must not think only of medicine and its allied services. Education, social security payments, housing assistance and support of food supplies, all promote health. In France, the Social Budget covers all these, and health service is less than a quarter of the whole, which in turn, takes nearly a quarter of the G.N.P.I8 Who can affirm that it should take more at the expense of others? Surely the key to the future of our Welfare State is a sensible partnership between the professions, within individual professions and with the community itself. Only in this way can our common aim - the health and welfare of all people - be achieved.
people
budget
-
-
-
-
REFERENCES M. et al. (1974). The Work of the Nursing Team in General Practice. Council for the Education and Training of Health Visitors. Edinburgh University. 2 HMSO (1967). The Place of the Voluntary Service in After Care. Second Report of the Working Party (Reading Report). 3 SKEET, MURIEL AND CROUT, E. (1977). Health Needs Help. Blackwells Scientific Publications Ltd. 4 GILMORE, M. et al. (1974). The Work of the Nursing Team in General Practice. Council for the Education and Training of Health Visitors. Edinburgh University. 5 BRITISH MEDICAL ASSOCIATION. Board of Science Education (1974). Primary Health Care Team. B.M.A. 6 HMSO (1977). Report of the Wolfenden Committee on Voluntary
1 GILMORE,
Organisations.
7 SKEET, MURIEL (1970). Home from Hospital. Macmillans Publish-
ing Co. Ltd. 8 Ibid. 9 SKEET, MURIEL AND CROUT, E. (1977). Health Needs Help. Blackwell Scientific Publications Ltd. 10 HMSO (1976). First Report from the Select Committee on Violence in the Family, Session 1976/77 Vol.1. (The Court Report). 11 SKEET, MURIEL (1970). Home from Hospital. Macmillans Publishing Co. Ltd. 12 HMSO (1968). Report of the Committee on Local Authority and Allied Personal Social Services. (Seebohm Report). 13 AVES, G. M. (1969). The Voluntary Worker in the Social Services. George Allen and Unwin. 14 NEWELL, KENNETH (Editor) 1975. Health by the People. World Health Organisation. 15 HOCKEY, LISPETH (1966). Feeling the Pulse. Queen’s Institute of District Nursing. 16 EHRLICH, D. A. (Editor) (1975). The Health Care Cost Explosion: Which Way Now? Hans Huber. 17 SKEET, MURIEL AND ELLIOTT, KATHERINE (1978). Health Auxiliaries in the Health Team. Croom Helm Ltd. 18 EHRLICH, D. A. (1975). The Health Care Cost Explosion: Which Way Now? Hans Huber.
NURSING AND THE COMPUTER Continued from page 11
due to the directives issued by the detail of an individual’s record will be required in the future. This system is, in principle, similar to a personnel system but an additional requirement that the system must perform is that of routine monitoring functions, giving early warning of nurses in training who are falling behind the requirements of the General Nursing Council.
examination.
EEC,
Also,
even more
BENEFITS that systems for nursing administration similar benefits to those of other computer systems, namely that clerical tasks can be reduced, results can be presented easily in many different formats, and the computer can be used for prompting human memory. In the case of nurse management, however, the benefit which comes from computerization is that one is now tackling problems where one could only scratch the surface using manual methods. Furthermore the problems being tackled are fundamental, namely how to allocate staff, including nurses in training, to wards in such a way that: The needs of the patients are catered for exactly at all times. Student nurses are allocated to wards in such a way that the training needs of the student are met, there are no large fluctuations in the numbers of students present, and senior staff are available to give them the teaching that they need. A solution to this problem could both reduce costs significantly and at the same time give vastly improved patient care, since it is widely accepted that there is a direct correlation between improved staff morale, resulting from the removal of frustrations, and the more rapid recovery of patients. In describing these systems it is necessary to emphasize the important role that nurses themselves can play in the early design work: It is of paramount importance that the system should do precisely what its users require of it, and that the users know not only what the system will do but also what their part will be in operating it. It is important to set up committees or working parties involving all grades of staff. It is important to consider all eventualities of a system in the design stage to avoid the situation of apathetic users when it is discovered that the computer system does not give some important information. Computer technology is likely to lead to an increased emphasis or standardization of decision making. Given that one has the relevant information nurse managers can forecast future events leading to greater staff satisfaction, better communication, improved staff morale and hence improved patient care. The systems described have of course related exclusively to hospital based systems. This does not mean that computers cannot be used in the community field where it is just as important to be able to assess workload measurement, maintain records and allocate resources available. IT do
IS THE case
bring
These papers were Services Group, 14
presented at a meeting of September 1978.
Downloaded from rsh.sagepub.com at University of Otago Library on June 5, 2016
the R.S.H.
Nursing
Tapping Voluntary Resources
in the Welfare
State THE PRACTICAL PROBLEMS MURIEL SKEET
Consultant, W.H.O. Headquarters, Geneva, formerly Chief Nursing Officer, British Red Cross Society HERE ARE many definitions of the word ’role’, a generally accepted one is that it constitutes the behaviour expected of an individual by virtue of his occupying a specified position in a social situation (Gilmore et al. 1974).’ Role expectations are perceptual, existing in the mind of the performer and in the minds of those with whom he associates in carrying out his work. But,expectations do not remain in the mind. They tend to become communicated, sometimes as direct instructions, at other times less directly; for instance, when admiration or disappointment in some performance or behaviour is expressed by a colleague. Low congruence in perceptions among group members in regard to their roles may not only be disfunctional for the provision of a service, but may mean that the individual feels his identity is not being recognised and respected by those with whom he works. Defining ’volunteer’ is more difficult for there is more than one category of such a person. The Working Party on the ’Place of Voluntary Service in Aftercare’ appointed by the Home Office under the Chairmanship of the Dowager Marchioness of Reading in its second that is to report2 distinguished between associates say volunteers ’who can provide support for a considerable period by a personal relationship’, and other volunteers ’whose contribution is more likely to be of a short duration in the way of a simple practical task or advice on a technical problem not requiring personal involvement’. The Working Party drew attention to the fact that ’there will always be truly independent persons and organizations who do not want any official contact or recognition and yet wish to offer a service’. Ten years later, another study designed to discover the role of the volunteer in the re-organised Health Service confirmed that statement.33
but
-
TEAM MEMBERSHIP ONE OF THE recommendations from that study was ’Volunteers in the health field working in the community should form part of the Primary Health Care Team and a member of that team should be responsible for their in-service training, their supervision, their follow-up assessments and for giving them continuous encouragement and support. Similarly those working in hospitals should come under the supervision of a senior member of the nursing staff to whom they should be responsible and accountable’. Integration as a member of the team is difficult if not impossible if the volunteer is responsible to a lay organiser whilst all other members are responsible to a senior member of one of the professions. A task should only be delegated to a volunteer and accepted by him if he is safe in carrying
out the procedure. An must be the judge.
expert in that particular field
It follows that accountability is something which given very careful consideration as the personal responsibility of each individual professional member of the team must be borne in mind. For this reason, every member of the team - whether professional or amateur - must be fully informed of the others roles, duties, specialised skills, interests, and responsibilities and limits of competence. The characteristics which occur with the greatest frequency in the literature on team work and which are considered to be most important in its development, have been set out by the authors of ’The Work of the Nursing Team in General Practice’.4 must be
These are: (i) that members of the team share a common purpose which binds them together and guides their actions (ii) that each member of the team has a clear understanding of his own functions; appreciates and understands the contributions of the other (professions) represented on the team and recognizes the commonness of interest and skill (iii) that the team does the practising by pooling knowledge, skills and resources and that all members share responsibility for the total outcome of their decisions. (iv) that the effectiveness of the team is related both to its capabilities to carry out its work and its abilities to manage itself as an independent group of people. Leadership only becomes a problem when there is lack of mutual respect and trust. The report of the Panel on Primary Health Care Teams (British Medical Association, 1974)5 stated: ’As the team is composed of members from a number of complementary disciplines, it is essential to define the objective of all its members so that there is a clear definition of their roles’. To learn a professional role, one goes through a specific educational programme designed to teach those skills and give that knowledge essential to carrying out the work within that role. Training is also a means of introducing a newcomer to the expectations of other members of the team and of providing them with the opportunity to identify with it. Surely this must apply to the amateur in the health or social service team, as well as to its professional members. However, in order to integrate the volunteer (who, we must remember, is not always an amateur) it is
Downloaded from rsh.sagepub.com at University of Otago Library on June 5, 2016
24 necessary to have the acceptance and the co-operation of three parties: the volunteers themselves, the professionals and the patients. In considering the practical problems met with in tapping the voluntary resources which is my remit I suggest we take each available of those groups in turn. And whilst there are many publications and reports including the latest one on Voluntary Organizations produced by the Wolfenden Committee6- I intend to advance ideas and base opinions on personal experience and gleanings I have had the privilege to gather during my own professional life. First in order of priority and importance - the -
-
-
-
patient. PROBLEMS OF THE PATIENT FIRST THE needs, and then the problems encountered in trying to get them met. I make no apology for including in the needs, those which were discovered during an enquiry undertaken eight years ago.’ I offer only the explanation that I know - and most of the audience will know - that similar experiences are to be found today. With more people living longer, the plight of old people, especially those recently discharged from the security, warmth and servicing of hospitals and Homes, occupies the attention and the conscience of many a social worker. The burden also falls squarely on the shoulders of the nursing members of the Primary Health Care team. We have known the curing role of the medical profession: that medical intervention is frequently dramatic and puts doctors in the teamleader position. But we are moving to new and expanding roles for other professions, because the people we keep alive longer rightly or wrongly - give nursing intervention an important place. This applies not only to the phenomenon of longevity, we also have disabled and drug- and machine-dependent patients living in the community who, a few decades ago, would have been dead. Those of you who have read Home from Hospita 18 will remember that examples were given of the different needs of patients discharged from hospitals. A variety of thumb-nail sketches were presented. These have sometimes been criticized: called journalese or described as the ’worst’ examples the study team discovered. They were neither. They were factual case histories written with no comment. Those unmet needs described in the report, included basic nursing procedures, such as the renewal of a dressing, the installation of ear or eye drops, help with dressing or undressing, bathing, washing, getting to the W.C. etc. Then there were a large number of patients who needed inforand their families and friends mation, advice and reassurance; elderly patients who had fractured their femurs missed the reassurance and encouragement of physiotherapists; others needed advice on rest or activity, or the expected effects of treatment such as chemo- or radio-therapy; on diets; on appliances and prostheses; on drugs and pain. Young mothers needed help with new babies. Old people requiring chiropody were housebound for no other reason but that their toe-nail problems prevented them from walking. Of course people do receive advice and instructions before discharge, but the older ones forget quickly and the younger ones confessed that they had not really -
-
-
paid attention; they were too excited, or preoccupied with the practical problems about going home. Others did not know about the services which were available locally; these included the laundry service, the
lending of for which
nursing equipment and the financial benefits they were eligible. Help with shopping, cooking, washing-up, bedmaking and also housework and gardening was often required, whilst the homehelp service requested sometimes did not materialise. Patients in the higher age group, especially surgical and orthopaedic patients, those with long-term illnesses and those living alone, experienced the greatest inconvenience. Relations, friends and neighbours often rallied but patients disliked the resulting feeling of obligation and dependance. Relying on relations not living with them produced anxiety because of the uncertainty involved and some people spoke of having to wait until the evening to be helped to the bathroom or to have their bed made, because this was the only time their helpers could come. Although no questions were asked about the serving of food, several women patients spoke of this and of the husband-produced or child-produced meal trays, carrying a whole plastic bag of bread and milk still in the bottle. ’Just one meal a day served with the feminine one said, ’would make so much difference. And of you may remember the example I gave of the patient who needed a listening post: Mrs. Z. Aet. 30 years. Acute lymphatic leukaemia. Chemotherapy and radiotherapy. Anxious for discharge to husband and two-year-old son. After discharge she missed the security hospital had given. Afraid of ’collapsing’ and of symptoms becoming too distressing. Attempted to take up the domestic responsibilities and the gay social life she was used to but felt weak and tired. This inability to do what she wanted, and her physical appearance, including swollen neck glands and poor condition of skin and hair, aroused frustration and anger which quickly led to depression, tears and temper. She hated the radiotherapy outpatient department and waiting with other patients ’gloomily discussing their symptoms’. Yet Mrs Z. was aware that this was her own great need. She did not want to bore her friends and distress her family and ’desperately wanted someone to talk to whom she did not know.’ She was ’smothered’ by family and friends who wanted to help, yet she could not use them - they were too close. Her great need was for ’a stranger who would listen’. Those then were some of the needs which were discovered. Nothing new, but to put facts down in black and white produces ’ammunition’ for people to fire. Identical needs were still unmet six years later, when another study to discover the role and preparation of volunteers was undertaken.9 In addition to those described above, it was established that there were increased needs in the fields of rehabilitation and health education. Stroke patients and their families needed instruction and encouragement with speech and physio-therapy; relatives needed to be taught how to perform competently basic nursing procedures and techniques which they were having to undertake at home for ill and infirm members. Again mothers needed on-going education: with non-accidental injury to young children,’° the increased incidence of head-lice, impetigo and rickets one cannot ignore this large field which presents scope for the well-informed volunteer. Young housewives knew little or nothing of first-aid; accidents cause more deaths among children in this country than any one disease. Who are the Lay volunteers? experts in that subject? Among the services recommended&dquo; to receive urgent attention were:
touch’, some
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...
25
(a) (b)
in half-way houses to provide accommodation and necessary services for old people. A door-to-door transport service for ill and elderly patients discharged from hospital or care
undergoing regular treatment as outpatients. (c) Home-help and Meals-on-Wheels service operating daily; the lay staff receiving support and encouragement from professional members of the Primary Health Care team. (d) A night-sitter service to relieve families and friends of patients who are ill or dying at home. (e) Organization of voluntary helpers of all ages to cook, serve meals, garden, shop, launder, do housework and to provide company, interest, and encouragement for those in special need, particularly the old and the lonely. Most of these services do not require to be delivered by someone with a training of three years or more; many needs could be met by a well-prepared and, in some cases, an adequately trained volunteer. Why were they not? From the patients’ points of view, primarily because they and their families did not know about already existing services and they did not know how to set about creating a demand for those not available. And when they had a vague idea that something of the kind existed, they did not know where to go for it. Another problem especially highlighted in rural areas, was the patient’s resentment of any intrusion of his privacy by a neighbour. It is for this reason that some street-warden schemes which have been initiated in various areas of this country, have failed; the patient or his family do not want neighbours seeing inside the home, finding out that the linoleum is torn or that the sheets are darned. Pride can be a mixed blessing...
because of lack of personnel. The earlier discharge of from hospital had brought more demands in some areas than their members could possibly cope with. Preparation of homes for patients returning from hospital was considered an important service, and one for which more helpers were needed. One Centre had found that a good source of supply for this particular service was retired nurses who, suffering ’from the ’scrap-heap syndrome’ in the late fifties and sixties, were delighted to find that they could be useful again. Often the ’established’ organizations said that it was difficult to recruit because ’everyone goes out to work these days’. Yet the vast majority of volunteers from ’new’ associations and also the independent volunteers interviewed, were in full employment. In fact many of the services were needed during, what are, for most the early morning, late people, non-working hours evening and at weekends. Experience has proved that telling people about a particular need in their own community usually stimulates offers of help. People rarely offer help in a vacuum, they need to be aware that their help is needed. Just as they want to know how their money is going to be used before giving it to a Charity, so they will also want to know how their time will be spent before offering it to a voluntary organization. Many will also need assurance that preparation for the job will be
patients
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forthcoming. By involving the community in discovering the needs on its own doorstep, members of it will often proffer ideas on how to meet them. They will also help to implement plans, and, finally, help in their evaluation. On-going assessments of their work and services are sadly absent from the plans of most voluntary organisations. Some have become introspective and continue without question or judgement, their traditional forms of service
PROBLEMS OF THE VOLUNTEER AND VOLUNTARY ORGANISATIONS SADLY THESE two studies also made another discovery ; the services needed were not always those which volunteers wished to provide. Some services are more popular than others and this explains, to some extent, the duplication of services which exists. Unfortunately some organisations provide a service they consider necessary rather than finding out by local surveys, what is actually needed in their area. In the first study, Home from Hospital, no detailed description of the work of any individual member of staff of either a statutory or a voluntary service was obtained; only a superficial picture of the organisation and of the delivery of its services was asked for. Organizers for the W.R.V.S. reported understaffing in both areas where the enquiry took place. Young women, they said, were employed by local industry and many who would have helped the W.R.V.S. had nowhere and no-one with whom to leave their children. The time spent in talking to people was considered important but often had to be cut because of the pressure of numbers. Helpers often reported adverse home conditions and particular cases of hardship they encountered. Whilst social workers were usually sympathetic, they could not always respond because they too were working under considerable pressure. Volunteers ’signposting’ in this way without contributing to solutions, added to the professionals’ load instead of helping to ease it. Recruitment was also a major problem of the Red Cross officers included in the study. They reported that requests for help frequently had to be turned down
others dabble in so many activities that they provide no one excellent service. Instead of searching for solutions to today’s problems, many opt for palliative measures. Often they are seen as ’not doing very much’ - a state not likely to attract new recruits. If voluntary agencies are to make their mark and obtain publicity they must earn it by providing services which are needed. Sometimes the service offered may be the right one, but is given under the wrong circumstances. As one patient with a progressive disease said, ’The voluntary organizations will provide transport to attend their own clubs and outings, but I don’t necessarily want to be with people with whom a physical disability is the only thing I have in common. I should like to visit my own friends for a meal, but transport to enable me to do so is just not there’. The time a service is available is also important. One of the greatest gaps in the statutory services is caused by the closure of departments at weekends and over Bank Holidays. Yet many voluntary organizations close at the same times. Medical Loan equipment is often needed at weekends but in many areas the depots of both statutory and voluntary agencies close down from Friday afternoon to Monday morning. In many parts of the country, the statutory meals-on-wheels service is discontinued for four or five days over Easter and Christmas: so is that of voluntary organizations. Too often, volunteers and voluntary agencies are providing the services they want to provide and not those which the patients/clients need. It has been made clear during group and individual discussions in which I have been involved, that greater co-ordination, collaboration, communication and co-
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26
operation are vitally needed not only between statutory and voluntary sectors of our Welfare State, but also between the voluntary organizations and volunteers themselves. Individual characteristics should be preserved, but to save the professionals’ time and also to be able to meet the need quickly, the voluntary organizations should consider Seebohm’s one-door principle. Not only would it provide one telephone point where all requests for voluntary help could be made, but it would also provide one recruiting point and a centre for the deployment of volunteers. Jack Ashley’s comments on associations for the deaf have wider implications: ’There are too many fragmented organizations, each dealing with its own specialized aspect of the problem and in many cases with specialized groups of people. At present, despite some attempts to co-ordinate their activities, deaf organizations leave themselves vulnerable to petty jealousies and parochial conflicts’. These petty jealousies and parochial conflicts result not only in a waste of resources, but also contribute to people’s general confusion and ignorance regarding voluntary
organizations. During our fieldwork, the following statement from the Report of the Committee on Local Authority and Allied Personal Social Services (Seebohm Report 1968) 12 was underlined time and time again: ’The ways in which existing resources are organised and deployed are inefficient. Much more ought to be done in the fields of prevention, community involvement, the guidance of voluntary workers and in making fuller use of voluntary organisations’. At the present time there appear to be minimal results from the many services voluntary workers offer. The low awareness of agencies and volunteers is indicative of this. Whilst there is an enormous investment of devotion there is a deplorable lack of return. The whole subject of preparation and training of Volunteers working in the Welfare State requires more study. However it is believed that all training should include the three elements of knowledge, skill and understanding. Obviously preparation or training for a job depends on the job to be done. But any amateur working with a patient or client requires at the very least, briefing on matters such as confidentiality. The Aves Committee (1969)&dquo; thought that ’volunteers who will be involved in close personal relationships, whether their work is the befriending of a lonely person or is concerned with helping people who have complex problems, will need, above all, to know something of human reactions and behaviour. They may need help in understanding the feeling and attitudes of clients and in realising that the relationship has to be one of mutual acceptance. They need to learn something of the arts of communication and establishing relationships, of how to give and receive information and respect confidences’. It is important too, that they should be able to judge how far they can go in dealing with a difficult situation and when and where to turn to for advice and help. In planning training it is necessary to bear in mind, not only the demands which the work will make on the volunteer, but also his own experience, capacity and attitudes and the resources which are available for training and continuing guidance or support. The amount of information, skill or awareness which volunteers may need to acquire will depend on these factors and will vary greatly, but it is essential that each volunteer should be helped to see how his learning can be applied to his work. Any training scheme which fails
to enable him to
apply his knowledge can achieve little, defeat its aim by confusing him or undermining his confidence. Who is to provide that preparation? That training? After the Second World War, trained V.A.D.s were accepted members of the ward nursing staff in many hospitals in this country. Members of the National Hospital Service Reserve received their training and gained their practical experience in hospitals of the N.H.S. Ward Sisters knew what tasks they could be called upon to undertake because, more often than not, they had taught them. It would seem logical that today’s professionals should train or prepare today’s volunteers to be their assistants. and may
even
PROBLEMS OF THE PROFESSIONALS DO THE professionals want that task? Do they want volunteers who will help them in their work? What about their reputation of being unreliable? What about Trade Union repercussions? Legal implications? The possibility of litigation? Certainly it would appear that there is an urgent need for professional staff working for the Welfare State to be prepared for working with volunteers. They must see them as assistants to themselves, working under their supervision: volunteers are not, and must never be seen as, alternatives to professionals. Even in times of emergency and epidemics, they must always be supervised by qualified staff. But in order that they may be effective and competent at those times, they must be given opportunities to practise in real-life situations. Professional members of the health and welfare teams should also be provided with information concerning voluntary organizations, their work and the services they provide. Such preparation should be included in their training programmes. It is not the exclusive right of the so-called caring professions to help people. Today we have a caring community. ’Health by the People’’4 is not only for Third World countries. Now, as never before, there is the need and the opportunity for professional staff members of the Welfare State to work with, as well as for, the community. People helping people has been the backbone of British social life for centuries, and although it may be called consumer participation in our time, nevertheless, help in this form is still needed. Self reliance must be taught especially in the preventive and promotive fields of medicine. Here people can help people to help themselves taught initially by -
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qualified personnel. Voluntary organizations with their unique pioneering function can implement innovative programmes without waiting for Committees to be convened or for questions to go up the scale and answers to slowly return down again. It is for this reason that Voluntary organizations must stamp on any sign of bureaucracy if
it appears in their midst and it is for this reason that they must never allow themselves to be totally Statefinanced. Their independence is their strength. They can - if their leaders are imaginative and courageous provide a service when it is needed, where it is needed and for whom it is needed. Can we afford not to use volunteers in the Welfare State? Studies have shown that in Britain we are -
deploying community nursing personnel inefficiently. 15 have expensively trained staff with high qualifications and great experience, who are sometimes used ineffectively. How can we conserve our resources? We
The cost of the National Health Service for 55 million
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27 in the United Kingdom is 75 times the annual of the World Health Organisation. 16 This cost has increased explosively during the past 15 years. Administrative changes were brought about in 1974 to help organise services in a more economical way. Has this been achieved? It may be that health care can be better and more economically achieved by different combinations of disciplines, professionals and auxiliaries. We have an obligation to save skilled time which is a most expensive commodity. Yet health professionals in particular have this inbuilt resistance to health auxiliaries. In a recent global study of the subject it was shown time and time again that resentment at the deployment of auxiliaries came from doctors and nurses and the greater of these came from nurses.&dquo; Health service is an open-ended commitment and more can always be done given the resources, material and human. Have our professions the right and the conscience to limit those human resources? The health professions are notoriously conservative and understandably so they undertake onerous responsibilities and part of their personal defences against doubt arise from the established certainties within their professions and sciences. But we must not think only of medicine and its allied services. Education, social security payments, housing assistance and support of food supplies, all promote health. In France, the Social Budget covers all these, and health service is less than a quarter of the whole, which in turn, takes nearly a quarter of the G.N.P.I8 Who can affirm that it should take more at the expense of others? Surely the key to the future of our Welfare State is a sensible partnership between the professions, within individual professions and with the community itself. Only in this way can our common aim - the health and welfare of all people - be achieved.
people
budget
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REFERENCES M. et al. (1974). The Work of the Nursing Team in General Practice. Council for the Education and Training of Health Visitors. Edinburgh University. 2 HMSO (1967). The Place of the Voluntary Service in After Care. Second Report of the Working Party (Reading Report). 3 SKEET, MURIEL AND CROUT, E. (1977). Health Needs Help. Blackwells Scientific Publications Ltd. 4 GILMORE, M. et al. (1974). The Work of the Nursing Team in General Practice. Council for the Education and Training of Health Visitors. Edinburgh University. 5 BRITISH MEDICAL ASSOCIATION. Board of Science Education (1974). Primary Health Care Team. B.M.A. 6 HMSO (1977). Report of the Wolfenden Committee on Voluntary
1 GILMORE,
Organisations.
7 SKEET, MURIEL (1970). Home from Hospital. Macmillans Publish-
ing Co. Ltd. 8 Ibid. 9 SKEET, MURIEL AND CROUT, E. (1977). Health Needs Help. Blackwell Scientific Publications Ltd. 10 HMSO (1976). First Report from the Select Committee on Violence in the Family, Session 1976/77 Vol.1. (The Court Report). 11 SKEET, MURIEL (1970). Home from Hospital. Macmillans Publishing Co. Ltd. 12 HMSO (1968). Report of the Committee on Local Authority and Allied Personal Social Services. (Seebohm Report). 13 AVES, G. M. (1969). The Voluntary Worker in the Social Services. George Allen and Unwin. 14 NEWELL, KENNETH (Editor) 1975. Health by the People. World Health Organisation. 15 HOCKEY, LISPETH (1966). Feeling the Pulse. Queen’s Institute of District Nursing. 16 EHRLICH, D. A. (Editor) (1975). The Health Care Cost Explosion: Which Way Now? Hans Huber. 17 SKEET, MURIEL AND ELLIOTT, KATHERINE (1978). Health Auxiliaries in the Health Team. Croom Helm Ltd. 18 EHRLICH, D. A. (1975). The Health Care Cost Explosion: Which Way Now? Hans Huber.
NURSING AND THE COMPUTER Continued from page 11
due to the directives issued by the detail of an individual’s record will be required in the future. This system is, in principle, similar to a personnel system but an additional requirement that the system must perform is that of routine monitoring functions, giving early warning of nurses in training who are falling behind the requirements of the General Nursing Council.
examination.
EEC,
Also,
even more
BENEFITS that systems for nursing administration similar benefits to those of other computer systems, namely that clerical tasks can be reduced, results can be presented easily in many different formats, and the computer can be used for prompting human memory. In the case of nurse management, however, the benefit which comes from computerization is that one is now tackling problems where one could only scratch the surface using manual methods. Furthermore the problems being tackled are fundamental, namely how to allocate staff, including nurses in training, to wards in such a way that: The needs of the patients are catered for exactly at all times. Student nurses are allocated to wards in such a way that the training needs of the student are met, there are no large fluctuations in the numbers of students present, and senior staff are available to give them the teaching that they need. A solution to this problem could both reduce costs significantly and at the same time give vastly improved patient care, since it is widely accepted that there is a direct correlation between improved staff morale, resulting from the removal of frustrations, and the more rapid recovery of patients. In describing these systems it is necessary to emphasize the important role that nurses themselves can play in the early design work: It is of paramount importance that the system should do precisely what its users require of it, and that the users know not only what the system will do but also what their part will be in operating it. It is important to set up committees or working parties involving all grades of staff. It is important to consider all eventualities of a system in the design stage to avoid the situation of apathetic users when it is discovered that the computer system does not give some important information. Computer technology is likely to lead to an increased emphasis or standardization of decision making. Given that one has the relevant information nurse managers can forecast future events leading to greater staff satisfaction, better communication, improved staff morale and hence improved patient care. The systems described have of course related exclusively to hospital based systems. This does not mean that computers cannot be used in the community field where it is just as important to be able to assess workload measurement, maintain records and allocate resources available. IT do
IS THE case
bring
These papers were Services Group, 14
presented at a meeting of September 1978.
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the R.S.H.
Nursing
